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STATE OFCALIFORMA , ""••s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B W ft 02 13, o' COMP &E A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ElEr3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 015 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: - /077Y I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A. OWNER'S TANK I.O. s B. MANUFACTURED BY: Tno%Z C. DATE INSTALLED (MO/OAYNEAR)D. TANK CAPACITY IN GALLONS: . . II.TANK C ENTS IFA -1 IS MARKED, COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B.C. 1aREGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ lb PREMIUM 4 GASAHOL (❑ � 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED � UNLEADED 5 JETFUEL 7 METHANOL OTHER (DESCRIBE IN ITEM D. BELOYI 0. IF (A.1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED 99 C. A. S. s: III. TANK CONSTRU ION MARK ONE ITEM ONLY IN BOXES A. 8, AND C. AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 1 RUBBER LINEDALKYO LINING 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED LINING ill❑ 95 UNKNO99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES •_ NO D. CORROSION ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 INYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U W A U 3 LINED TR A U 95 UNKNOWN C. MATERIAL AND A U 1 BARE STEEL A U STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑ 99 OTHER V. TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 NTORY RECONCILIATION 3 VADOZE MONITORING 4 AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING 6 TANK TESTING H 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ gg OTHER VI. TANK CLOSURE INFORMATION i. ESTIMATED DATE LAST USED (MO/DAYNR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL ? YES = NO= THIS FORM HAS BEEN COMPLETED UNDER PENALTY nF PFA.II /L7v a Ain — Tuc ?ECT - - -• •--• • ucu. yr WIT MvVWL&UUl:, lS /HUEAND COR APPLICANTS NAME I WED a $*MATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D. NUMRFR IS cnluonscn ncruc cnrle.InAanen-, .,... - - - vn nVnlpGilJ OCLV Y� COUNTY STATE I. D.# D7# JURISDICTION # FACILITY # TANK # G ANP�(oy E===] PERMIT s PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATIONDATE3 3 /J INOu n THIS 9012U LII ICT DC APY+r1AIn AAurn - --• -------,.•• n' -Hill /V-rua.04I1VPl • rVtiM A, UNLt55 A CUHHENT FORM A HAS BEEN FILED. ii / FOROOSlB-RB